Published on January 15, 2008
Breastfeeding the premature and the sick baby: Breastfeeding the premature and the sick baby Jack Newman, MD, FRCPC In retrospect, it has become obvious that incubator care is a large factor in the difficulty establishing breastfeeding in premature and sick babies. : In retrospect, it has become obvious that incubator care is a large factor in the difficulty establishing breastfeeding in premature and sick babies. Is incubator care the only way, or even the best way to take care of premature and sick babies?: Is incubator care the only way, or even the best way to take care of premature and sick babies? Early skin to skin care: Early skin to skin care Bergman NJ, Linley LL, Fawcus SR. Randomized controlled trial of skin-to-skin contact from birth versus conventional incubator for physiological stabilization in 1200-2199 gram newborns. Acta Paediatr 2004;93:779-785 Two groups: Two groups All babies were put skin to skin on the mother after birth. After the five minute Apgar, if stable (monitored continuously), they were divided Skin to skin care (SCC) for 6 hours Transferred to incubator and “usual” care Protocol: Protocol All babies had an IV line placed with glucose running at 4.17 mg/kg/min All had an orogastric tube placed All were started on theophylline by orogastric tube Oxygen given if required If the baby was well, breastfeeding attempted at 50 min, 3 hours and 5 hours After 6 hours, all babies given routine care Babies were continuously monitored: Babies were continuously monitored Parameters: Parameters All babies were monitored and watched for parameters exceeded Skin temperature below 35.5°C for two consecutive recordings Heart rate <100 or >180 for two consecutive recordings Apnea >20 seconds O2 saturation <87% despite support Blood glucose <2.6 mmol/l confirmed by lab SCRIP score: SCRIP score Kangaroo Mother Care: Kangaroo Mother Care Kangaroo Mother Care: Kangaroo Mother Care If medical condition stabilized: Infant is placed naked between mother’s breasts Facilitates breastfeeding Maintains baby’s physiological functions at least as well as, and often better than incubator care Kangaroo Mother Care: Kangaroo Mother Care Fewer apneas and bradycardias Less frequent and less severe desaturation Oxygenation improved Body temperature maintained Earlier discharge from hospital Improved arousal regulation and stress reactivity Kangaroo Mother Care: Kangaroo Mother Care Infants cry less and cry is not of distress type Provides analgesic effects during painful procedures Less stress in baby (shown by decreased ß endorphin release, cortisol) Positive effects seem to be maintained after contact ended Better parent-child relationship Greater likelihood of full breastfeeding in hospital and at discharge Gas exchange: Gas exchange Föhe K, Kropf S, Avenarius S. Skin to skin contact improves gas exchange in premature infants. J Perinatology 2000;5:311-15 53 preterm infants <1800 g in a prospective study, during incubator care (60 min), skin to skin contact (90 min) All babies on oxygen, 5 still being ventilated References: References Cattaneo A, Davanzo R, Worku B, et al. Kangaroo Mother Care for low birthweight infants: A randomized control trial in different settings. Acta Pædiatr 1998;87:976-85 Törnhage C-J, Sturge E, Lindberg T, Serenius F. First week Kangaroo Care in sick very preterm infants. Acta Pædiatr 1999;88:1402-4 Johnston CC, Stevens B, Pinelli J et al. Kangaroo Care is effective in diminishing pain response in preterm neonates. Arch Pediatr Adolesc Med 2003;157:1084-8 References: References Feldman R, Weller A, Sirota L, Edelman AI. Skin-to-skin contact (Kangaroo Care) promotes self-regulation in premature nfants: sleep-wake cyclicity, arousal modulation and sustained exploration. Develop Psychol 2002;38:194-7 Charpak N, Ruiz-Peláez JG, et al. A randomized controlled trial of Kangaroo Mother Care: Results of followup to 1 year corrected age. Pediatrics 2001;108:1072-9 References: References Ohgi S, Fukuda M, Moriuchi H, et al. comparison of kangaroo care and standard care: Behvioral organization, development and temperament in healthy low birth weight infants through 1 year. J Perinatology 2002;22:374-9 Furman L, Minich N, Hack M. Correlates of lactation in mothers of very low birth weight infants. Pediatrics 2002;109(4) www.pediatrics.org/cgi/content/full/109/4/e57 WHO document on KMC (2003): WHO document on KMC (2003) http://www.who.int/reproductivehealth/publications/kmc/kmctext.pdf All the references you could want Includes practical information for implementation of Kangaroo Mother Care Breastmilk and breastfeeding: Breastmilk and breastfeeding The premature baby: The premature baby The word “premature” covers a lot of ground. What may be true about the 26 week gestation baby, weighing 600 grams who is being ventilated for weeks, may not be true of the 33 week gestation baby, weighing 1600 grams, who is otherwise well. The latter has more in common with a full term baby than he does with that 26 week gestation premature baby. They both need breastmilk: They both need breastmilk But the methods of feeding them, the need for fortification, the approaches are very different. Each baby needs to be treated as an individual. The “one size fits all” approach to feeding premature babies is inappropriate. Generalizing from the NICU: Generalizing from the NICU Unfortunately, much of how we approach feeding the premature comes from NICU’s, neonatologists and paediatric nutritionists who deal with that 26 week gestation premature baby, but never see a healthy 33 week gestation baby. However, most premature babies fall into the latter group (they are relatively mature and large, often have only minor problems, and are in hospital essentially to get feeding). Let’s not generalize: Let’s not generalize We cannot take what may be appropriate for that 26 week gestation, tiny premature in a NICU as a basis for the nutrition of the bigger premature babies found in nurseries in most community hospitals. For example, if the mother is pumping enough milk, most babies of 33 or more weeks gestation do not need “fortification”. Different approaches are necessary for this group. Confession: Confession I did 6 months in a tertiary NICU as part of my training. But most of my experience in feeding premature babies comes from my Africa experience. babies who did not make it on oxygen alone, didn’t make it this is a different situation from NICU Still, that allows some perspective on the question of feeding premature babies: Still, that allows some perspective on the question of feeding premature babies Why breastmilk for the premature?: Why breastmilk for the premature? Breastmilk provides: Protection against infection. Protection against NEC. Appropriate lipid profile (PUFA’s). Better cognitive development. Better visual development. A role for the mother in the care of her baby. this is very important. And, for the same reasons that breastmilk is best for the full term baby.Premature babies don’t need breastmilk less, they need it more!: And, for the same reasons that breastmilk is best for the full term baby. Premature babies don’t need breastmilk less, they need it more! Alternatives to breastmilk?: Alternatives to breastmilk? There is lack of evidence for safety, superiority or even equality of the alternatives (preterm formulas and fortifiers) in the long term. We should be careful about using them routinely. They should be used as drugs, if necessary, but not if not necessary. Apparent deficiencies of breastmilk: Apparent deficiencies of breastmilk Not enough protein to support the growth of the premature baby. Insufficient calcium, phosphorus and vitamin D for bone mineralization. Insufficient calories for intrauterine growth rate. Intolerance of some tiny premature babies to lactose Intrauterine growth rate: Intrauterine growth rate Besides being intellectually satisfying, is there any proof that a baby who does not grow at intrauterine growth rates is worse off than the baby who does? No. Are there suggestions that more is not necessarily good? Yes. There are advantages to exclusive breastfeeding (or breastmilk feeding) that go beyond growth rate. A balance which is best for the baby needs to be struck. Advantages to exclusive breastmilk feeding?: Advantages to exclusive breastmilk feeding? Lipid profile in adolescents Singhal A, Cole TJ, Lucas A. Breastmilk feeding and lipoprotein profile in adolescents born preterm: follow-up of a prospective randomised study. Lancet 2004;363:1571-8 Two parallel study trials: Two parallel study trials 926 infants born preterm were randomly assigned in two parallel trials to receive Donated banked breastmilk or preterm formula Standard term formula or preterm formula as sole diet or as supplements to mother’s milk Results: Results “The ratio of LDL to HDL cholesterol was significantly lower in adolescents who had been randomised to bank breastmilk compared with those who received preterm formula” “CRP concentration was also significantly lower in adolescents randomised to banked breastmilk compared with preterm formula” “As expected, early weight gain was significantly greater in infants randomised to nutrient-enriched preterm formula than in those randomised to banked breastmilk” Is more weight gain necessarily better?: Is more weight gain necessarily better? “As expected, early weight gain was significantly greater in infants randomised to nutrient-enriched preterm formula than in those randomised to banked breastmilk” The more breastmilk a baby got, the lower his LDL to HDL ratio (better profile): The more breastmilk a baby got, the lower his LDL to HDL ratio (better profile) Different Study, same Cohort: Different Study, same Cohort Effects on blood pressure Singhal A, Cole TJ, Lucas A. Early nutrition in preterm infants and later blood pressure: two cohorts after randomised trials. Lancet 2001;357:413-9 Osteopænia, fractures etc.: Osteopænia, fractures etc. Bone demineralization is often cited as a reason to use fortifiers And there does appear to be a benefit to giving extra calcium and phosphorus to prevent osteopænia in very small premature babies But of course, it is not necessary to give cow’s milk (from which fortifiers are made) in order to give extra calcium and phosphorus Calcium and phosphorus can be added to breastmilk without using fortifiers, based on individual evaluation of biochemical factors One long term study: One long term study Bishop NJ, Dahlenburg SL, Fewtrell MS, et al. Early diet of preterm infants and bone mineralization at age five years. Acta Pædiatr 1996;85:230-6 Compared banked donor milk vs preterm formula as a supplement to mother’s breast milk in 54 children aged five years Results: Results “Increasing human milk intake was strongly positively associated with later bone mineral content.” “Children fed predominantly human milk had greater bone mineral content than children of similar size born at term.” Implications?: Implications? “…a period of mineral deprivation in the newborn period is good for long term bone mineralization! This would represent another example of programming. It could represent the action of other factors within breastmilk, such as growth factors”¹ ¹Ryan S. Bone mineralization in Preterm Infants. Nutrition. 1998;14:745-747 Let’s look at how feeding of the premature baby is often undertaken: Let’s look at how feeding of the premature baby is often undertaken One case study: One case study Twins girls born at 33 weeks gestation Normal delivery Mother nursed a previous child 7 months without problems MH born at 2.02 kg (4lb 7oz),VH born at 1.6 kg (3lb 8oz) No problems at all in hospital (5 weeks total, 3 weeks in one, then 2 weeks in another hospital) Feeding in hospital: Feeding in hospital Intravenous for first 4 days Formula started early, nasogastric feedings at first Bottles started within the first week Breastfeeding only attempted after several weeks (mother not sure exactly when) Pumping started in hospital but mother not sure when (not within first days) What’s wrong with that?: What’s wrong with that? The mother should have started expressing immediately (but it was not encouraged) No skin to skin care The babies could have been tried on the breast as soon as it was obvious they were stable (<24 hours in this case) Cup feeding would have been preferable to bottles and even to ng feedings Formula was not necessary in the first days On discharge from hospital: On discharge from hospital Mother was essentially bottle feeding, with babies taking the breast a little on the left, refusing the right side completely Each feeding consisted of approximately 60 ml (2oz) of formula with 30 ml (1oz) of expressed milk First visit to our clinic: First visit to our clinic The babies are 83 days old MH weighs 3.35 kg (7lb 6oz) (birthweight was 2.02 kg) weight gain 16 g/day, well below intrauterine growth rate VH weighs 3.25 kg (7lb 2oz) (birthweight was 1.6 kg) weight gain 20 g/day, better but still below intrauterine growth rate The babies’ weights: The babies’ weights What do you think? MH gained 1.33 kg in 83 days which works out to 16 g/day VH gained 1.65 kg in 83 days, which works out to 20 g/day Intra-uterine growth rate: Intra-uterine growth rate The “experts” say that premature babies need to grow at intra-uterine growth rates or 12 to 16 grams/kg/day (Nutrient needs and feeding of premature babies. Statement of the Canadian Paediatric Society, 1995) Therefore, when they left the hospital, according to this standard, MH should have weighed 2.85 kg and VH 2.27 kg and at term, , MH, 3.21 kg, et VH, 2.54 kg (conservative estimate using 12 g/kg/day) What does this mean?: What does this mean? If they had, in fact, grown at that rate in hospital, MH would have gained only 140 g since discharge from the hospital 5 weeks before, and VH 710 g in the same time So two possibilities: They didn’t grow at intra-uterine growth rates in hospital (which is the likely answer, despite all the fortifier and preterm formula they got) They didn’t grow well since leaving hospital despite being mostly formula fed, and shouldn’t we be concerned about that? After 4 visits over 4 weeks: After 4 visits over 4 weeks MH weighs 4.02 kg, VH, 3.81 kg (increase of 530 g for MH et 460 g for VH in 3 weeks) They are getting 120 cc/day of supplemental formula a day or ±60cc/baby/day Both are breastfeeding beautifully Let’s look at the weights: Let’s look at the weights Did they gain enough? MH gained: 530/21=25 g/day VH gained: 460/21=22 g/day Do we really truly need to check weight gain/day? Nobody seemed to be worried that the weight gain was not up to intra-uterine rates when they were being supplemented with formula, were they? For formula, everything and anything is permissible: For formula, everything and anything is permissible After 5 weeks of help in our clinic, with the mother obviously very determined, babies are exclusively breastfeeding and gaining weight well: After 5 weeks of help in our clinic, with the mother obviously very determined, babies are exclusively breastfeeding and gaining weight well Known deficiencies of artificial feedings: Known deficiencies of artificial feedings No protection against infection. No trophic factors. epidermal growth factor is only one No long chained polyunsaturated fatty acids (PUFA’s). Bioavailability of many elements poor or much reduced. Interaction of elements does not occur. Breastmilk made to measure: Breastmilk made to measure Fortifiers: Fortifiers Because of the insufficiencies of each, then the use of fortifiers is the “ideal” solution? Benefits of both, right? No, because fortifiers dilute the benefits of breastmilk alone. They may be helpful or even necessary, but in the case of liquid fortifier, dilute breastmilk or in the case of powder, makes it hyperosmolar. Always necessary? No! Overcoming “deficiencies” of breastmilk: Overcoming “deficiencies” of breastmilk Feed more! a healthy, unstressed premature may tolerate a lot more than a sick, tiny one we had no option in Africa; babies could get breastmilk only; I was convinced by the “intrauterine growth rate” argument so we gave them more, and when the roof didn’t cave in we gave even more How much more?: How much more? Usually it is said that premature babies can take only up to 180 to 200 cc/kg/day fluid by gut. In some NICU’s, the “rule” is even less. in an NICU this may make sense since the babies are sick and some may go into heart failure with more fluid. but the well premature baby can take more, especially if given by continuous ng feeding. We gave 300+ cc/kg/day with no trouble except occasionally babies would get diarrhea. Continuous drip: Continuous drip It has been said this isn’t as good as intermittent feedings, because of greater loss of fat. Others studies suggest the oppositeless fat loss with continuous flow But if the syringe is tip upwards, we lose less fat. Ultrasound homogenization can decrease fat loss as well. In utero the baby gets continuous flow. Lecithin to decrease fat loss: Lecithin to decrease fat loss Chan M, Nohara M, et al. Lecithin decreases human milk fat loss during enteral pumping. J Ped Gastroenerol Nutr 2003;36:613-15 Adding 1 g of soy lecithin to 50 ml of human milk decreased fat loss from 58% (±13%) to 2% (±2%) Overcoming “deficiencies”: Overcoming “deficiencies” Use hindmilk (more fat, faster growth) Use fresh milk immediately after pumped we found that when mothers had to leave, and refrigerated milk was used, babies grew less well Add calcium, vitamin D and phosphorus without using fortifiers Use commercial lactase to incubate with expressed milk Kangaroo care Need more weight gain?: Need more weight gain? If the mother is producing sufficient milk, why not centrifuge some of the mother’s milk, skim off the fat, and add it to the baby’s feedings? Easy to do. We did it in Africa, with no equipment except a centrifuge. Individualize care: Individualize care The approach is different depending on the baby. bigger babies (>1500 g) usually do not need fortification (“dilution” would be the appropriate word in this case). a healthy baby, even small, presents fewer issues than a sick one (this does not mean a sick baby should not get breastmilk) Milk banking: Milk banking Why do “fortifiers” need to be made with cow’s milk? The technology is there (after all we make “fortifiers” from cow’s milk) to make fortifiers from human milk. This has been done, and it is conceivable that individual items can be ordered up. baby needs more proteinphone the milk bank to get human milk protein baby needs to gain moreget human milk fat Milk banking: Milk banking Milk banking also affords us the luxury of getting human milk into the baby from the very first days, if the mother’s supply is not yet up to scratch. Early feeding is now felt to be best for most premature babies. Usually a small amount of human milk is much better than large amounts of formula (preterm or otherwise). Getting breastmilk: Getting breastmilk First of all you need to get the milk. Milk from a breastmilk bank is one option Some mothers have no intention of breastfeeding, but they should be approached. “This is the one thing you can do for your baby that nobody else can. You will be providing the best medicine there is for your premature baby. Won’t you help us help him?” Early feeds: Early feeds Colostrum should be provided as soon as possible. Even drops may be beneficial, by “priming” the baby’s gut and giving protective SIgA. Drops can be tolerated even by the tiniest baby and even drops protect. Many premature babies have IV lines up, so there is no rush to get fluids into them. Small amounts of colostrum are perfectly acceptable, and safer than early introduction of foreign proteins. From the Canadian Paediatric Society: From the Canadian Paediatric Society Nutrient needs and feeding of premature babies. 1995 “During the transition period, when growth is variable and infants are metabolically unstable, all infants, regardless of birth weight, should receive a combination of parenteral and enteral nutrition. “Expressed preterm-mother's milk, without fortification, is the first choice for enteral feeding during this period.” Priming the gut: Priming the gut The baby is much more likely to tolerate oral feedings earlier. Trophic factors (epidermal growth factor is present in high concentrations in colostrum) help the gut mature. growth of villae and digestive enzymes promote gut “closure” increase absorption of nutrients improve gut motility Sending a message: Sending a message Even a drop or two of colostrum can be used for mouth care of the ventilated baby, even mixed with some water Giving the few drops to the baby sends a very strong messageeven a few drops of breastmilk are important and good Treat the milk as if it were precious! Because it is. Informed consent: Informed consent The mother should know that even if the baby gets only colostrum, she is helping the baby’s health and improving chances of the baby getting out of hospital earlier rather than later. She should know how her breastmilk will decrease the baby’s chances of infection and necrotizing enterocolitis. She should know that his intellectual development may be better if he gets her milk. What if no IV is necessary?: What if no IV is necessary? Small amounts of fluids may be adequate colostrum in drops for a day or two. if mother not yet producing, and more calories neededhow about banked milk? IV should be seriously considered to avoid formulas in the first days, so as not to lose the advantage of the baby’s getting only breastmilk orally during this most important time. Starting out expressing: Starting out expressing Start as soon as possible after the baby’s birth. The sooner one starts, the more milk the mother is likely to produce, and the sooner the baby has colostrum available to him. The mother has more practice. Hand expression is often easier when quantities are small. Hand expressing in the NICU: Hand expressing in the NICU Pumping milk: Pumping milk Use double setup electric pump if possible. less time involved than single more milk results in higher prolactin levels most mothers prefer double setup How frequently?: How frequently? Mother should express as much as reasonable. eight times a day for about 20 minutes/side compression can be used as well towards end of pumping (increases milk supply, gets more milk) don’t forget hand expression! Support for the mother: Support for the mother It will not always be easy for the mother. She needs support in hospital. all health professionals should be expected to convey the message of the importance of breastmilk there will be rough moments She needs support outside hospital. La Leche League, outside LC Handling milk: Handling milk Best to use fresh pumped milk given to the baby immediately after pumping. Refrigerated better than frozen. The more you handle milk, the more you lose beneficial factors (but remember, even if you lose some SIgA, for example, there is no SIgA in formula). Glass and hard plastic presently the preferred containers. Cytomegalovirus: Cytomegalovirus One exception to fresh or refrigerated being better than frozen is the situation when mother is CMV positive and baby under about 28-30 weeks gestation. Freezing significantly reduces the viral load, so that the mother’s milk can be safely given to the baby. Not an issue if the baby was born older than about 28-30 weeks gestation. If born 28-30 weeks gestation, when is it okay to use unfrozen milk? One approach (San Diego): One approach (San Diego) All mothers delivering at less than 32 weeks are tested for serum IgG antibodies to CMV If negativefresh milk is given If positive IgG, even if milk is negative for virus, it is likely the mother will, at some time, excrete the virus in her milk. Milk is frozen until baby is >32 weeks gestation. What about breastfeeding?: What about breastfeeding? As one mother said to me about a Toronto hospital where she gave birth to two premature babies a few years apart, “They’ve changed. They now believe in breastmilk and are urging me to express my milk, but I don’t think they believe yet in breastfeeding”. When to start at the breast?: When to start at the breast? As soon as the baby is stable. babies can start nuzzling the breast very early let them learn to take the breast if you wait until they can coordinate suck and swallow, you will have lost much valuable time Kangaroo care, mother and baby (or father and baby) skin to skin as much as possible is ideal. Pholosong Hospital, South Africa: Pholosong Hospital, South Africa 31 weeks, 3 days old, and breastfeeding: 31 weeks, 3 days old, and breastfeeding Note latch: Note latch When can the baby start?: When can the baby start? Nyqvist KH, Sjö P-O, Ewald U. The development of preterm infants' breastfeeding behaviour. Early Hum Dev. 1999;55:247-264 71 singleton (26.7-35.9 weeks gestation) studied prospectively Mothers made most of the observations, with help from experienced observers 4321 records of infants’ behaviour When can the baby start?: When can the baby start? “Irrespective of postmenstrual age, the infants responded by rooting and sucking on the first contact with the breast. Efficient rooting, areolar grasp and latching on were observed at 28 weeks” “Nutritive sucking appeared from 30.6 weeks” “Sixty-seven (out of 71) infants were breastfed at discharge. Fifty-seven of them established full breastfeeding at a mean postmenstrual age of 36.0 weeks (33.4-40.0).” "Restrictions in breastfeeding policies for preterm infants are commonly based on studies of bottle feeding, where it has been established that infants with immature cardiorespiratory control show a less coordinated suck-swallow-breathe pattern, resulting in apnea, hypoxia and bradycardia": "Restrictions in breastfeeding policies for preterm infants are commonly based on studies of bottle feeding, where it has been established that infants with immature cardiorespiratory control show a less coordinated suck-swallow-breathe pattern, resulting in apnea, hypoxia and bradycardia" From Kersten Nyqvist (email sent August 16, 2004): From Kersten Nyqvist (email sent August 16, 2004) …the postmenstrual age (PMA, corresponding to GA after birth) when preterm infants in the Uppsala NICU reach full breastfeeding has been decreasing gradually, with an increasing number of 34- and 33-weekers being discharged with full breastfeeding. We also see some 32-weekers fully breastfed, and recently one baby attained full breastfeeding at a PMA of 31 weeks and 6 days (GA verified by ultrasound). 28 weeks gestation, two weeks old, latched on, getting milk: 28 weeks gestation, two weeks old, latched on, getting milk 28 weeks and breastfeeding: 28 weeks and breastfeeding Consider this: Consider this Apparently in some or many Scandinavian NICU’s, mothers are encouraged not only to touch their babies, but also to hold them skin to skin, and also to lick their skin all over. Why on earth? Positioning, latching on: Positioning, latching on This is no less important for the premature baby than in the full term A good latch allows the baby to get milk better from the breast this teaches the baby to suckle properly babies learn to breastfeed by breastfeeding A good latch prevents nipple soreness Good position, good latch: Good position, good latch Nipple points to roof of mouth: Nipple points to roof of mouth Two errors?: Two errors? Two errors?: Two errors? Nipple is pointing to the lower lip, not upper lip (or has moved baby to much to the side) Mother is squeezing nipple to put it into the baby’s mouth Better: Better Well latched on: Well latched on 34 weeks, well latched on: 34 weeks, well latched on 31 weeks, drinking beautifully: 31 weeks, drinking beautifully A few contentious points: A few contentious points Do premature babies need nipple shields? Maybe some, but give them a chance to latch on without them. What’s the rush? If we did more skin to skin care (Kangaroo Mother Care), we would have babies latching on better and earlier If we didn’t feed premature babies by schedules, we would also not need nipple shields A few contentious points: A few contentious points Are test weighings so important? Do you really believe they tell you anything? What if you get a negative test weight? Why not just follow the baby’s weight from day to day? Observe the baby at the breast! A few contentious points?: A few contentious points? Do premature babies fall asleep at the breast because the are tired? Or because the flow of milk is slow? Right! Just as with a full term baby! Get the flow going, and they will keep away just as they would on a bottle How to prevent slow flow?: How to prevent slow flow? Best latch possible. Teach the mother how to know the baby is getting milk (open mouth widepauseclose mouth type of suck). Use compression when the baby doesn’t actually drink. Switch sides as the flow slows. Use a lactation aid to supplement (preferably expressed milk). Lactation aid: Lactation aid Use only after baby has nursed both sides and only after the baby no longer actually drinks. Is the best way to supplement because babies learn to breastfeed by breastfeeding. Even if there is no such thing as nipple confusion, lactation aid still best. baby continues to get milk from breast there is more to breastfeeding than breastmilk Lactation aid in place: Lactation aid in place Inserting tube-1: Inserting tube-1 Inserting tube-2: Inserting tube-2 Inserting tube-3: Inserting tube-3 Inserting tube-4: Inserting tube-4 Cup feeding: Cup feeding Best used when mother isn’t there. Used to avoid a bottle. Some people say that if used correctly, helps the baby to learn to breastfeed because he must stick out tongue to drink from cup. In any case it is easy, and better than bottle. Cup feeding: Cup feeding Cup feeding: Cup feeding Cup feeding: Cup feeding Finger feeding: Finger feeding Used essentially to help a reluctant baby to take the breast. It calms him, gets him suckling properly. After a few seconds to a minute or two of finger feeding, try the baby on the breast. If mother not there, cup feeding is better, there is no reason to use finger feeding. Finger feeding: Finger feeding Positioning of tube for FF: Positioning of tube for FF Positioning of tube for FF: Positioning of tube for FF So what about the “older” premature baby (35-37 weeks)?: So what about the “older” premature baby (35-37 weeks)? Nothing really The same approach is necessary An early start, good positioning and latching No forcing of the baby to the breast No rush to get him breastfeeding Avoidance of bottles Skin to skin contact (most of the day) Alternative feeding methods if necessary Discharge with good outside followup Discharge planning: Discharge planning There is no need to wait for the baby to breastfeed well, if the mother and baby can get early, reliable, frequent and knowledgeable followup, starting within a day or two of discharge. Should we intimidate mothers into giving bottles, so the baby can go home? short term gain, for long term pain Attrition of Breastfeeding In NICU from Admission to Discharge: Attrition of Breastfeeding In NICU from Admission to Discharge Attrition of Breastfeeding In NICU from Admission to Discharge 1500 gms: Attrition of Breastfeeding In NICU from Admission to Discharge 1500 gms Breastfeeding the baby with congenital heart disease: Breastfeeding the baby with congenital heart disease Why is it important to breastfeed?: Why is it important to breastfeed? For the same reasons as for any baby. Why does a baby with cardiac disease need breastfeeding (or breastmilk) less? S/he needs it more. They spend a lot of time in hospital, and infection rates are not minimal. Indeed infection is not rarely cause of complications, prolonged hospitalizations and death. What obstacles are there?: What obstacles are there? Same as any mother-baby pair plus: “Breastfeeding is more difficult than bottle feeding” Fluid restriction is “necessary” for the baby with congestive heart failure Cardiac disease often associated with other problems A baby who has had a cardiac transplant cannot breastfeed Is breastfeeding more difficult?: Is breastfeeding more difficult? Not according to the data Anyone who takes the trouble to watch a baby breastfeeding at the breast knows this is not true Marino BL, O’Brien P, LoRe H. Oxygen saturations during breast and bottle feeding in infants with congenital heart disease. J Pediatr Nurs 1995;10:360-4 Fluid restriction: Fluid restriction Fluid requirements can be managed clinically (daily weights, physical examination, increased use of diuretics) Even, if one must, pre and post feeding weights If truly necessary, though, the mother could: use a lactation aid with expressed milk while the baby nurses on a “dry” breast Still possible to avoid bottle with cup Associated problems: Associated problems Babies with cardiac problems often have other associated problems Trisomy 21 large tongue, hypotonia most babies will take the breast Tracheo-oesophageal fistula (other gi anomalies) no need for favourite surgeon formulas; breastmilk is best Cardiac Transplantation: Cardiac Transplantation Will antibodies in the milk increase the risk of rejection? Ridiculous! An example of breastmilk is guilty until proved otherwise, whereas formula is innocent until proved guilty. Antibodies in various fluids: Antibodies in various fluids In rare cases…: In rare cases… It would seem as if white cells in the milk gave information to the baby which resulted in an immune response to platelets in baby when the mother had idiopathic thrombocytopenic purpura, for example. Has never been reported with cardiac transplantation. Rare!! Often gets better after a few weeks. Freezing milk kills white cells. But would these cytokines overcome the powerful immunosuppressives? Chylothorax: Chylothorax Not a rare complication of cardiac surgery The thoracic duct is nicked, and lymph drains into the right chest cavity Rarely, a baby may be born with chylothorax without any obvious reason Treatment of chylothorax: Treatment of chylothorax Chest tube drainage + Low fat diet (to decrease lymph flow in the thoracic duct) Low fat diet?: Low fat diet? You cannot give an infant a low fat diet; this will result in poor growth So if we give him milk with medium chained triglycerides, the baby will get fat which is not absorbed into the lymph, but rather directly into the blood stream This will decrease the flow of lymph in the thoracic duct and decrease the drainage into the chest cavity Does that mean no breastmilk?: Does that mean no breastmilk? That’s what it meant until some people started to think about it a little. People who felt breastfeeding, or at least breastmilk, was important. Why give Portagen (formula with medium chained triglycerides) when we can give breastmilk? What to do?: What to do? Mother expresses milk. Milk is centrifuged and fat skimmed off. Fat is replaced by medium chained triglycerides. It’s not quite breastmilk, but it’s better than Portagen. Baby is also at lesser risk for infection and receives most of the other benefits of breastfeeding. And then?: And then? Once the thoracic duct heals, the baby goes back to breastmilk, and attempts are made to get the baby breastfeeding. It may not be easy, as most surgeons and cardiologists want the chest dry for several weeks before abandoning the milk with medium chained triglycerides. If the baby were fed on a “dry breast” with a lactation aid? Making skimmed breast milk: Making skimmed breast milk See: http://home.earthlink.net/~chester2001/ Breastfeeding the baby with cystic fibrosis: Breastfeeding the baby with cystic fibrosis Why is it important to breastfeed?: Why is it important to breastfeed? For the same reasons as for any baby. Why does a baby with cystic fibrosis need breastfeeding (or breastmilk) less? S/he needs it more. They spend a lot of time in hospital, and infection rates are not minimal. Indeed infection is a common cause of complications, prolonged hospitalizations and death. Nutrition is a serious issue for these babies. Breastmilk is best. Breastmilk has lipase: Breastmilk has lipase These babies usually do not have good pancreatic function and are unable to digest fat well. But mother’s milk contains lipase. These babies usually do not digest protein well. But mother’s milk contains proteases. Most babies will need enzymes: Most babies will need enzymes These can be given, dissolved in some expressed milk, by lactation aid Sometimes, because they are digestive enzymes, the mother’s nipples can become sore So use all purpose nipple ointment before passing enzymes through the tube Fat excretion studies: Fat excretion studies Part of the “routine” workup for cystic fibrosis is to do fat excretion studies. The baby is given milk of which the fat content is known. His bowel movements are collected for five days and the amount of fat in the bowel movements is measured. The amount of fat excreted in the stools is expressed as a percentage of the total fat ingested Normal fat excretion: Normal fat excretion Normally, a baby will not have more than about 10% of the total fat intake recovered in the stools. An older child or adult, no more than 5%. Babies with cystic fibrosis usually pass much more than 10% of their fat intake in the bowel movements. What are the implications?: What are the implications? It means taking the baby off the breast and feeding by bottle for 5 days. Often they are not even offered the mother’s milk because the amount of fat in breastmilk is variable. It means that many babies will then refuse to breastfeed, having gotten used to the bottle Is it necessary to do this?: Is it necessary to do this? It helps to decide how much enzyme replacement the baby will need. It helps to get research published to know this figure of %fat excreted. But enzyme replacement is, in any case, a bit of a guess, and can be adjusted. And is it worth depriving the baby of breastfeeding and breastmilk? Breastfeeding and PKU: Breastfeeding and PKU Phenylketonuria: Phenylketonuria A rare inborn error of metabolism, characterized by the child’s inability to oxidize phenylalanine to tyrosine. It is caused by the absence of active phenylalanine hydroxylase in the liver. Up until about 15 years ago, it was thought that breastfeeding was impossible (another example of bottle feeding mentality). Then it was shown that breastmilk had less phenylalanine than formula. Can the baby breastfeed?: Can the baby breastfeed? A baby with PKU needs some phenylalanine, but not too much, so breastfeeding can be encouraged. How do we make sure the baby with PKU gets some, but not too much, since the amount a baby would get from full breastfeeding is usually too much for him? First approach at PKU clinic: First approach at PKU clinic Mother weighs baby before feeding. Mother feeds baby 10 minutes on each side. Mother reweighs baby after feeding. Mother gives rest of calculated total of feeding as low phenylalanine containing formula. Why didn’t it work?: Why didn’t it work? The mother had to take a scale with her wherever she went. Babies started to refuse the breast. Is anyone surprised? Babies usually stopped by 2-3 weeks of age. Another way?: Another way? Calculate the approximate quantity of low phenylalanine formula the baby would require. Give this amount of formula at the beginning of the feeding at the breast with a lactation aid. Allow the baby to finish the feeding on the breast. Results?: Results? During the first year, breastfeeding continued much longer. One baby made it to 18 months of age. Several made it to 6 months. One baby who had atypical PKU was able to be breastfed exclusively. If you look you, may find a way. Lactation aid: Lactation aid Cup feeding: Cup feeding Finger feeding: Finger feeding If you believe in the importance of breastfeeding, both to the mother and the baby,: If you believe in the importance of breastfeeding, both to the mother and the baby, and you have imagination and determination,: and you have imagination and determination, and develop the necessary skills,: and develop the necessary skills, even in the most difficult, complex, or previously untried situations,: even in the most difficult, complex, or previously untried situations, you may find a way!: you may find a way!